A nurse is receiving a change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process?
Set client-centered, measurable and realistic goals.
Critically analyze client data to determine priorities.
Determine effectiveness of interventions.
Collect and organize client data.
The Correct Answer is D
A. Set client-centered, measurable and realistic goals: This occurs during the planning stage, after data collection and analysis.
B. Critically analyze client data to determine priorities: This step happens after data collection during the diagnosis phase.
C. Determine effectiveness of interventions: This is part of the evaluation stage, which comes after planning and implementation.
D. Collect and organize client data: This is the first step in the nursing process, where the nurse gathers comprehensive information about the client's physical, psychological, sociocultural, developmental, and spiritual needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Pincer grasp: The pincer grasp, which involves using the thumb and forefinger to pick up small objects, typically develops around 8 to 12 months of age, not at 4 months.
B. Rolls from tummy to back: At 4 months, many infants start to develop the ability to roll from their tummy to their back. This is a typical milestone for this age and reflects developing motor skills.
C. Walks with support: Walking with support usually begins around 9 to 12 months of age, much later than 4 months.
D. Rolls from back to tummy: Rolling from back to tummy typically occurs a bit later, often around 5 to 6 months. At 4 months, rolling from tummy to back is the more expected milestone.
Correct Answer is C
Explanation
A. Provide music as an environmental distraction: This might help in some contexts but is not typically necessary for preparing for a physical exam. Clear communication is more important.
B. Make sure the room temperature is cool: Older adults often have reduced ability to regulate body temperature and may find cooler environments uncomfortable. A comfortable room temperature is preferable.
C. Explain to the client what is about to happen: Clear explanations can reduce anxiety, increase cooperation, and ensure that the client understands the process, which is crucial for effective assessment and trust.
D. Inform the client that the provider will examine sensitive areas first: Sensitive areas are usually examined last to maintain comfort and build trust.
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